Podcast Summary: The AOFAS Orthopod-Cast

Episode: Bone Infection Management Tools You Should Know

Date: October 8, 2025
Host: Dr. Kent Dallington (Charlotte, NC)
Guests: Dr. Chris Krulin (UC Davis, Sacramento, CA) & Dr. Victor Anciano (University of Louisville Health, KY)
Sponsor: BONESUPPORT™ (Cerament® G)

Episode Overview

This episode dives deep into advances in bone infection management, with a focus on the surgical use of Cerament G—a synthetic, antibiotic-loaded bone void filler. Host and panelists share in-depth clinical experience, review pivotal research articles, discuss practical surgical techniques, and debate multidisciplinary care models aimed at limb salvage and infection eradication in complex orthopedic cases.

Key Discussion Points and Insights

1. What is Cerament G?

[02:50 - 08:37]

• Composition: 40% hydroxyapatite, 60% calcium sulfate, loaded with gentamicin sulfate.
• Mechanism: Injectable, resorbable bone void filler with high local antibiotic delivery, matching bone formation resorption rates.
• Advantages:
  • Allows for single-stage surgery versus traditional multiple-stage protocols.
  • Proven lowest reinfection and refracture rates vs. other synthetic substitutes.
  • Remodels into host bone within 6–12 months.
  • Gentamicin elution is localized, avoiding systemic toxicity and supporting patients with compromised renal function/comorbidities.
• Clinical Use Cases: Open fractures (prophylactic), active infections (osteomyelitis), infected nonunions, especially for high-risk patients (smokers, diabetics, peripheral vascular disease).

“If you don’t have a local high dose concentration antibiotic delivery, those bacteria are never going to see the antibiotics... and thus you have recurrent infection. So local delivery of Cerament G allows us to really, you know, kill the bugs that are causing these problems for us.”
— Dr. Kent Dallington [06:20]

2. Landmark Study #1: McNally et al., JBJS 2022 – Single-Stage Chronic Osteomyelitis Treatment

[08:37 - 15:36]

• Study Details: 100 patients, 6-year mean follow-up, single-stage surgery with Cerament G
• Key Results: 94% success rate (only 6% recurrence).
• Critical Elements:
  • Multidisciplinary “triple visit” approach—orthopedics, infectious disease, plastics all involved in single-stage OR visits.
  • Emphasis on meticulous soft tissue management and immediate coverage.
  • Protocol-driven, team-based care improves consistency and outcomes.
• Potential U.S. Practice Gaps: Opportunity for U.S. teams to adopt similar coordinated care for better outcomes.

“The key there was communication between plastics and the orthopods and then it was all done in one case, in one visit to the operating room… The numbers were great, but also that they just have a very good protocol.”
— Dr. Chris Krulin [09:41]

• Gentamicin Delivery Point: Achieved concentrations above MIC locally, even overcoming some resistant organisms due to high local doses.

“Even a bug that might be gentamicin resistant at the MICs most likely is not gentamicin resistant at these high doses.”
— Dr. Chris Krulin [11:25]

3. Clinical Reflections & Multidisciplinary Approach

[13:17 - 19:43]

• Not a Magic Bullet: Cerament G is a powerful tool, but fundamentals (thorough debridement, standard surgical care, comprehensive teamwork) remain critical.
• Systemic Antibiotic Use: New protocols may allow early cessation of IV/PO antibiotics post-op, reducing healthcare resource utilization, patient inconvenience, and risk of systemic antibiotic complications or resistance.
• Suitability for Renal/Compromised Patients: Extremely valuable where IV gentamicin is unsafe.

“Sometimes we cannot give them the antibiotics we want to because of either their dialysis schedule or their chronic kidney disease. So this comes into play for that.”
— Dr. Victor Anciano [17:37]

4. Landmark Study #2: Pomeroy & McNally, J Orthop Science 2024 – Cerament G with Intramedullary Nailing

[19:43 - 28:35]

• Technique: Inject Cerament G into reamed canal and/or coat intramedullary nails before nailing tibias/femurs for infected/non-union cases.
• Benefits Over PMMA:
  • No hardware extraction needed.
  • Not radio-opaque or obstructive on imaging.
  • Reduces OR time and additional surgeries.
• Clinical Results: 91% infection-free at 1-year follow-up for open fractures/nonunions.
• Technical Pearls:
  • Inject Cerament when mixture is “soupy”—otherwise nail insertion is difficult.
  • Allow material to set longer for bone voids (“toothpaste” consistency).
  • Keep tourniquet inflated during application to minimize bleeding, optimize cement adherence.

“All you need is one debridement with cerumen for that to work. And ever since then, I was a believer of the single stage procedure.”
— Dr. Victor Anciano [44:13]

“You don’t have to create the nail… You have that cement there that doesn’t leak away—it stays and helps dilute over 28 days to really fight off any infection.”
— Dr. Chris Krulin [24:35]

Addressing Complications:

• Cerament Leak/‘Chalky Drainage’: Common but benign; distinguish from purulent drainage.
• Use of Toucan Cannula and cannulas in kit optimize canal delivery.
• “Silo” technique for large voids: create multiple drill holes, vacuum via Fraser tip, slowly fill with Cerament.

5. New Indications: Cerament G with 3D Cages and Total Ankle Replacements

[35:16 - 42:19]

• 3D Cage Use:
  • Fill porous cage structure and surrounding bone with Cerament G—elutes antibiotic into critical zone.
  • “Silo technique” ensures even antibiotic distribution.
• Infected Total Ankles:
  • Used as part of staged revision; potential for single-stage conversion in selected cases (drawing on hip/knee literature).
  • Local delivery crucial, especially for patients unsuitable for systemic antibiotics.

“Once that infection’s gone, everything starts healing. The bone heals, the wound heals, the tissues granulate in. And sure enough, I saw that.”
— Dr. Chris Krulin [45:33]

6. Real-World Case Examples & Takeaways

[43:08 - 46:25]

• ‘Aha’ Cases:
  • Successfully salvaged digits/limbs in high-risk patients—efficacy after multiple failed standard treatments.
  • Technique now extended to major amputations—Cerament G injected into remaining bone, aiming to minimize post-amputation infection complications.

“Whether it’s a toe, a transmet, or below or even above knee amputation…if you can take infection off the block, at least you’re just dealing with a wound problem versus an infected wound.”
— Dr. Kent Dallington [46:02]

Notable Quotes & Memorable Moments

• On Multidisciplinary Success:
  “They have infectious disease, orthopedic surgeons, and the infectious disease people all working as a team… That’s why they can have such a great algorithm and maintain a strict protocol.”
  — Dr. Chris Krulin [09:12]

• On Cerament G’s Impact:
  “You almost can’t overdo it here. Those cases are all hands on deck when it comes to infection control and biology and you know, 3D printed designs and hindfoot fixation.”
  — Dr. Kent Dallington [41:08]

• On Adopting New Protocols:
  “I think as you start to use it more and kind of test it out, you do see that it does work. And what the data shows is easy to replicate in your practice.”
  — Dr. Chris Krulin [45:47]

Technique Tips & Pearls

• Cerament G injection timing: Insert when mixture is slightly loose for canal, firmer for bone voids.
• Leak management: Expect and identify “chalky” drainage in ~5–10% of cases; reassure patients.
• Use of tourniquet & suction: Maintains cement concentration and reduces bleeding during application.
• Toucan Cannula & Silo Drill Techniques: Assure optimal distribution in complex canals/cages.

Timestamps of Major Segments

• [02:50] — Cerament G overview & clinical utility
• [08:37] — McNally paper/results & UK experience
• [13:17] — Multidisciplinary team approaches
• [15:36] — Gentamicin levels & antibiotic strategy
• [19:43] — Pomeroy paper: IM nail coating with Cerament G
• [28:35] — Technique pearls: injection, tourniquet, “silo,” cannula
• [35:16] — Cerament with 3D cages & total ankles
• [43:08] — Case examples & conclusion

Conclusion

The episode presents Cerament G as a transformative tool for orthopedic infection management—empowering single-stage surgeries and limb salvage in cases once considered hopeless. The evidence from landmark studies, practical tips, and a shift towards multidisciplinary, protocol-driven care points to a new era in complex bone infection management.

To those new to Cerament G or advanced bone infection work, this conversation delivers both foundational knowledge and field-tested clinical wisdom—enabling improved patient outcomes and efficiency in practice.